Resident Handbook

Scheduling:

• As of April 2021, in-person appointments will be the default for resident clinic.  All residents and attendings scheduled for resident clinic are expected to be in the Frenkil clinic during the scheduled clinic session.

  • If follow-up patients are not able to come in, they will be offered telemedicine visit.

  • Initial patient visits will only be in-person.

Policy on staffing of patients:

• PGY-2 residents staff patients with attending in real time and patient seen by attending all year.

• PGY-3 and PGY-4 residents staff all initial patients in real time and patient seen by attending.

• Follow-up patients seen by PGY-3 and PGY-4 residents may leave clinic without being seen by attending.  Patient should be discussed with the attending sometime during the clinic session.  If there are any changes to the plan suggested by the attending, the resident is responsible for calling the patient or following up as appropriate.

Tips to improve patient flow and teaching:

1. Focus on efficiency and on the problem at hand.

2. Focus on the proper presentation format. Make sure you don’t allow sloppy presentation styles.

3. If possible, observe the resident doing all or part of an exam. If you see 3 patients with the same resident and you watch a different part of the exam each time, you can give feedback on the exam without sacrificing efficiency.

4. Remind residents to utilize the Colored Dot system in Epic to indicate the encounter status: 

• WHITE: Pt being triaged.  When that is complete MA will change dot to BLUE 

• BLUE: Ready to be seen by physician. Physician gets patient from waiting room and changes dot to GREEN. 

• GREEN: Pt being seen by physician.  When done with patient and they are walking out to check-out, change dot to RED.  

• RED: Visit completed. 

5. Keep track of the patient flow:

• If multiple residents are waiting to staff, try not to spend too much time with one resident/patient.

• If one resident has multiple patients waiting, see if there is another without a patient who can offer a patient the option of seeing them instead. 

• No residents should leave clinic until all patients are being seen (the only exception is the VA consult resident who is scheduled for an abbreviated clinic)

6. Do not ramble on about “when I was in residency”, “back in the old days”, or “Before Epic….”. These are not important or relevant. Focus on the case at hand and the current practice of neurology.

7. Attempt to summarize your teaching experience with 1 or a few clinical pearls about the case or patient even if it is just approach, or style.

8. Use of AAN Parameters and Guidelines: There are numerous AAN practice parameters (some detailed below) that should be used in daily clinical practice and by referring the residents to them you will show them an invaluable educational resource to read AND you will show them how we are not “just making this up” based on our experience. There are real metrics and parameters that guide practice. Guidelines can be found at: https://www.aan.com/Guidelines/

9. Review the residents’ notes and give feedback. It takes only a few minutes and is simply invaluable to their education. Even for PGY4’s, assume that their documentation needs improvement, and thus you should peruse their note and give feedback. 

10. If you see a good case together, pull a paper or two and sent to the resident.

Steps to Co-sign notes and close encounters in Epic:

1. Open the “Cosign Notes” folder in your Inbox and click on note 

2. Read through note  

   • Send Resident an Epic message (or other communication) if there is feedback you have regarding their notes 

   • If there are things that you would like to correct or add to the resident's documentation, you can include them in you “Quick note” (see step 2) 

   • If you feel that the resident's note is so wrong that it must be redone, you can reach out to the resident and ask them to reopen and addend the encounter. 

3. Create "Quick Note" (The system will not let you sign the encounter without entering a note) 

   • On the top bar next to the "sign" button select the "Quick Note" button 

   • The format for the Quick Note was changed in ~March 2021 so that there is now a default setting that asks for a recipient for the note (see screenshot below).  You need to deselect the “Route as Chart Cosign” button so that you can sign the note without a recipient (otherwise the encounter will not close after you sign your note).

• In the “quick note” progress note, enter your attending attestation  

1. General system attending attestations are under .TP (for teaching physician) 

2. You are welcome to use some from Carolyn Cronin’s smartphrases: .CACTP (for patients seen with resident) and .CACTPNOTSEEN (for follow-ups staffed but not seen)

• Make any edits or additions to the documentation 

4. Sign the quick note.

5. SIGN and close encounter: click the "Sign" button at the top 

Tele-medicine visits

1. On the day of clinic schedule in Epic will indicate whether it is planned for in-person, Telemedicine (video), or Telephone visit.

• The AAs to indicate in the appointment notes whether it is an Initial or follow-up patient and whether it is a zoom or phone call appointment.

2. The information for each zoom visit can be found in the "Notes" section of each appointment on the schedule.

• Right click on appointment in schedule and select “Show appointment report”. 

• Scroll down to the “Scheduling and arrival information” section and you will see the Zoom meeting ID and Password, which you can then type or cut and paste into zoom.

3. For Initials for PGY2-4 and Follow-ups for PGY2 you will staff patient by logging into the zoom meeting, OR

• If the resident is seeing a patient without zoom capability that they need to staff in real time (e.g. PGY2 with follow-up), they will call your cell phone and merge you into the phone call with the patient for staffing.  

4. Follow-up patients for PGY3-4 residents can be staffed with the resident at the end of clinic.  If there is a complex follow-up patient that they would like to have you see and staff in real time, they will reach out.

5. Compliance / Billing – elements needed for telemedicine visit

• Consent:

In the note, include: .TELEHEALTHVIDEOVERBALCONSENTCOVID19 (and complete blanks).

OR

Go under “Express lane” tab, select type of encounter (e.g. Video due to social distancing).  Scroll up to Orange header and select appropriate consent type (e.g. video) and complete the blanks.

• Document start and end time of tele-visit (in note)

• “Charge Capture” section (under Wrap Up tab Or Express Lane): type in “COVID” and select COVID code

• “Level of Service”/ Professional fee billing (under Wrap Up tab Or Express Lane):  

1. For patients not seen by attending: Select the 88888 code in the professions fee billing section

2. For patients seen by attending: Select appropriate level of service for complexity of E&M service and documentation.

3. The Modifier code “95” should be added to indicate that it is a televisit

Urgent Clinic Attending responsibilities:

1. Be available to see a patient who needs to be seen urgently by special request.

• Whenever possible, patients will be seen by faculty in the appropriate subspecialty division.  The Urgent Clinic Attending will only be called upon in rare cases.

• If there is a patient who needs to be seen, you will receive an email. 

• Urgent Clinic is listed on the schedule for Wed afternoon.  However, if a patient needs to be seen during your week, you can add on an appointment on another day instead if you would rather.

2. Be available for residents to call when there is an outpatient issue that they need assistance with. 

• Typically, the resident will reach out to attending they previously saw the patient with or the appropriate subspecialist.  This is a plan B if the resident if those faculty are not available.

Appendix 1: Practice Parameter Examples that would be useful in outpatient neurology practice

• Practice parameter update:  Management issues for women with epilepsy--focus on pregnancy (3 part review)

• Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (BPPV) (Update) from the American Academy of Otolaryngology - Head and Neck Surgery

• Prevention of Stroke in Patients with Silent Cerebrovascular Disease: A Scientific Statement for Healthcare Professionals from the American Heart Association/American Stroke Association

• Practice Guideline Summary: Treatment of Restless Legs Syndrome in Adults

• Practice Advisory: Recurrent Stroke with Patent Foramen Ovale (Update of Practice Parameter)

• International Consensus Guidance for Management of Myasthenia Gravis

• Management of Adults with Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies

• Practice Guideline Update Summary: Botulinum Neurotoxin for the Treatment of Blepharospasm, Cervical Dystonia, Adult Spasticity, and Headache

• Practice Guideline: Idiopathic Normal Pressure Hydrocephalus: Response to Shunting and Predictors of Response

• Guidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

• Evidence-based Guideline: Management of an Unprovoked First Seizure in Adults

• Summary of Evidence-based Guideline Update: Evaluation and Management of Concussion in Sports

• Update: Steroids and Antivirals for Bell Palsy

• Update: Pharmacologic Treatment for Episodic Migraine Prevention in Adults

Appendix 2: The Five Microskills for Clinical TeachinG

Tip Sheet adapted from Neher et al. J Am Board Fam Pract 1992; 5:419-24

Updated: September 2022